HEALTH EXAMINATION RECORD

CS Form 86
Name : _________________________________________________ Division :___________________________________________ Department : ______________________________
Date of Birth : _____________________________________________ Type of Work: ______________________________________Sex: _________________ Civil Status : _________
Date : Date : Date :
1 Height : Height : Height :
Weight : Weight : Weight :
2 Temperature : Temperature : Temperature :
Respiratory System: Respiratory System: Respiratory System:
3 Flourography : Flourography : Flourography :
Sputum Analysis: Sputum Analysis: Sputum Analysis:
Circulatory System: Circulatory System: Circulatory System:
Blood Pressure : Blood Pressure : Blood Pressure :
4
Pulse: Pulse: Pulse:
Sitting : Agility Test: Sitting : Agility Test: Sitting : Agility Test:
5 Digestive System : Digestive System : Digestive System :
6 Genito-Urinary : Genito-Urinary : Genito-Urinary :
Urinalysis, etc.: Urinalysis, etc.: Urinalysis, etc.:
7 Skin : Skin : Skin :
8 Locomotor System: Locomotor System: Locomotor System:
9 Nervous System: Nervous System: Nervous System:
Eyes: Conjunctivitis, etc.: Eyes: Conjunctivitis, etc.: Eyes: Conjunctivitis, etc.:
10
Color Perception: Color Perception: Color Perception:
Vision: Vision: Vision:
11 With glasses: Far: _____ Near :_____ With glasses: Far: _____ Near :_____ With glasses: Far: _____ Near :_____
Without glasses: Far: _____ Near : _____ Without glasses: Far: _____ Near : _____ Without glasses: Far: _____ Near : _____
12 Nose: Nose: Nose:
13 Ear: Ear: Ear:
Hearing: Hearing: Hearing:
14
Right: Left: Right: Left: Right: Left:
15 Throat : Throat : Throat :
16 Teeth and Gums: Teeth and Gums: Teeth and Gums:
17 Immunization: Immunization: Immunization:
18 Remarks: Remarks: Remarks:
19 Recommendation: Recommendation: Recommendation:
Employee's Signature: Employee's Signature: Employee's Signature:
20
Employee's Name (Print) : Employee's Name (Print) : Employee's Name (Print) :
Physician's Signature : Physician's Signature : Physician's Signature :
21
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Physician's Name (Print): Physician's Name (Print): Physician's Name (Print):